Ctla-4 antibody dosage escalation regimens

ABSTRACT

A disease or condition, such as cancer or an infectious disease, can be treated in a patient by administering a CTLA-4 antibody in an escalating dosage regimen until a partial or complete response is elicited in the patient or a pre-determined maximum dosage is reached.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation application of U.S. application Ser.No. 13/335,232, filed Dec. 22, 2011, which is a continuation applicationof U.S. application Ser. No. 11/567,846, filed Dec. 7, 2006, issued asU.S. Pat. No. 8,110,194, which claims priority to U.S. Provisionalapplication Ser. No. 60/748,688, filed on Dec. 7, 2005, the contents ofeach of which are incorporated by reference in their entirety, and toeach of which priority is claimed.

SEQUENCE LISTING

The specification further incorporates by reference the Sequence Listingsubmitted herewith via EFS on May 18, 2014. Pursuant to 37 C.F.R.§1.52(e)(5), the Sequence Listing text file, identified as“0773750983SEQLIST.TXT,” is 3,687 bytes and was created on May 18, 2014.The Sequence Listing, electronically filed herewith, does not extendbeyond the scope of the specification and thus does not contain newmatter.

1. FIELD OF THE INVENTION

The present invention relates to methods of treating a disease, such ascancer or an infectious disease, in a patient by administering a CTLA-4antibody to the patient in an escalating dosage regimen until an optimumdosage is reached.

2. BACKGROUND OF THE INVENTION

The vertebrate immune system requires multiple signals to achieveoptimal immune activation (see, e.g., Janeway, Cold Spring Harbor Symp.Quant. Biol. 1989; 54:-14; Paul William E., ed. Raven Press, N.Y.,Fundamental Immunology, 4th edition (1998), particularly chapters 12 and13, pages 411 to 478). Interactions between T lymphocytes (T cells) andantigen presenting cells (APC) are essential to the immune response.Levels of many cohesive molecules found on T cells and APC's increaseduring an immune response (Springer et al., A. Rev. Immunol. 1987;5:223-252; Shaw and Shimuzu, Current Opinion in Immunology, 1988 Eds.Kindt and Long, 1:92-97; and Hemler, Immunology Today 1988; 9:109-113).Increased levels of these molecules may help explain why activated APC'sare more effective at stimulating antigen-specific T cell proliferationthan are resting APC's (Kaiuchi et al., J. Immunol. 1983; 131:109-114;Kreiger et al., J. Immunol. 1985; 135:2937-2945; McKenzie, J. Immunol.1988; 141:2907-2911; and Hawrylowicz and Unanue, J. Immunol. 1988;141:4083-4088).

T cell immune response is a complex process that involves cell-cellinteractions (Springer et al., A. Rev. Immunol. 1987; 5:223-252),particularly between T and accessory cells such as APC's, and productionof soluble immune mediators (cytokines or lymphokines) (Dinarello, NewEngl. J. Med 1987; 317:940-945; Sallusto, J. Exp. Med. 1997;179:1109-1118). This response is regulated by several T-cell surfacereceptors, including the T-cell receptor complex (Weiss, Ann. Rev.Immunol. 1986; 4:593-619) and other “accessory” surface molecules(Allison, Curr. Opin. Immunol.1994; 6:414-419; Springer, 1987, supra).Many of these accessory molecules are naturally occurring cell surfacedifferentiation (CD) antigens defined by the reactivity of monoclonalantibodies on the surface of cells (McMichael, Ed., Leukocyte TypingIII, Oxford Univ. Press, Oxford, N.Y., 1987).

CD28 antigen, a homodimeric glycoprotein of the immunoglobulinsuperfamily (Aruffo and Seed, Proc. Natl. Acad. Sci. 1987;84:8573-8577), is an accessory molecule found on most mature human Tcells (Damle et al., J. Immunol. 1983; 131:2296-2300). Current evidencesuggests that this molecule functions in an alternative T cellactivation pathway distinct from that initiated by the T-cell receptorcomplex (June et al., Mol. Cell. Biol. 1987; 7:4472-4481). Monoclonalantibodies (MAbs) reactive with CD28 antigen can augment T cellresponses initiated by various polyclonal stimuli (reviewed by June etal., supra). These stimulatory effects may result from MAb-inducedcytokine production (Thompson et al., Proc. Natl. Acad. Sci 1989;86:1333-1337; and Lindsten et al., Science 1989; 244:339-343) as aconsequence of increased mRNA stabilization (Lindsten et al., 1989,supra).

CTLA-4 (cytotoxic T lymphocycte-associated antigen-4) is accepted asopposing CD28 activity and dampening T cell activation (Krummel, J. Exp.Med. 1995; 182:459-465; Krummel et al., Int'l Immunol. 1996; 8:519-523;Chambers et al., Immunity. 1997; 7:885-895). CTLA-4 deficient micesuffer from massive lymphoproliferation (Chambers et al., supra). It hasbeen reported that CTLA-4 blockade augments T cell responses in vitro(Walunas et al., Immunity. 1994; 1:405-413) and in vivo (Kearney, J.Immunol. 1995; 155:1032-1036), exacerbates antitumor immunity (Leach,Science 1996; 271:1734-1736), and enhances an induced autoimmune disease(Luhder, J Exp. Med. 1998; 187:427-432). It has also been reported thatCTLA-4 has an alternative or additional impact on the initial characterof the T cell immune response (Chambers, Curr. Opin. Immunol. 1997;9:396-404; Bluestone, J. Immunol. 1997; 158:1989-1993; Thompson,Immunity 1997; 7:445-450). This is consistent with the observation thatsome autoimmune patients have autoantibodies to CTLA-4. It is possiblethat CTLA-4 blocking autoantibodies play a pathogenic role in thesepatients (Matsui, J. Immunol. 1999; 162:4328-4335).

Non-human CTLA-4 antibodies have been used in the various studiesdiscussed above. Furthermore, human antibodies against human CTLA-4 havebeen described as immunostimulation modulators in a number of diseaseconditions, such as treating or preventing viral and bacterial infectionand for treating cancer (e.g., PCT Publication WO 01/14424 and PCTPublication WO 00/37504). U.S. Pat. No. 5,855,887 discloses a method ofincreasing the response of a mammalian T cell to antigenic stimulationby combining a T cell with a CTLA-4 blocking agent. U.S. Pat. No.5,811,097 discloses a method of decreasing the growth of non-T celltumors by administering a CTLA-4 blocking agent. U.S. Pat. No. 6,984,720and U.S. Patent Publication No. 2002/0086014 disclose human CTLA-4antibodies. Each of these patents and applications is herebyincorporated by reference.

U.S. Patent Publication No. 2004/0241169 describes a treatment forcancer in which the target dosage of a CTLA-4 antibody for a patient isa dosage that results in an autoimmune event.

There continues to be a need for methods of administering an optimumdose of a CTLA-4 antibody for the treatment of a disease, such as canceror infectious disease, to a patient that meets a predetermined maximumdosage level, or results in a partial or complete response, andminimizes the incidence and/or severity of an adverse event.

SUMMARY OF THE INVENTION

This invention is directed to methods of administering a CTLA-4 antibodyto a patient in a dosage escalation regimen for treating a disease orcondition, such as cancer or an infectious disease, by administeringescalating dosages of the CTLA-4 antibody to the patient until anoptimum dosage is reached.

The present invention provides methods for treating cancer in a patientby administering a CTLA-4 antibody to the patient according to a dosageescalation regimen, which comprises administering increasing dosages ofthe CTLA-4 antibody to the patient until an optimum dosage is reached.

In one embodiment, the escalating dosage regimen includes a linearincrease in CTLA-4 antibody dosage. In another embodiment, theescalating dosage regimen includes a stepwise increase in CTLA-4antibody dosage.

According to the present invention, a dosage escalation regimen permitsa patient to receive an optimum dosage of a CTLA-4 antibody, which is adosage that results in a partial or complete response in the patient, oris a predetermined maximum dosage.

In an embodiment of the invention, a dosage of CTLA-4 antibody isadministered about every three weeks.

In a specific embodiment, the escalating dosage regimen includesadministering a first dosage of CTLA-4 antibody at about 3 mg/kg, asecond dosage of CTLA-4 antibody at about 5 mg/kg, and a third dosage ofCTLA-4 antibody at about 9 mg/kg.

In another specific embodiment, the escalating dosage regimen includesadministering a first dosage of CTLA-4 antibody at about 5 mg/kg and asecond dosage of CTLA-4 antibody at about 9 mg/kg.

Further, the present invention provides an escalating dosage regimen,which includes administering an increasing dosage of CTLA-4 antibodyabout every six weeks.

In an aspect of the present invention, a stepwise escalating dosageregimen is provided, which includes administering a first CTLA-4antibody dosage of about 3 mg/kg, a second CTLA-4 antibody dosage ofabout 3 mg/kg, a third CTLA-4 antibody dosage of about 5 mg/kg, a fourthCTLA-4 antibody dosage of about 5 mg/kg, and a fifth CTLA-4 antibodydosage of about 9 mg/kg. In another aspect of the present invention, astepwise escalating dosage regimen is provided, which includesadministering a first dosage of 5 mg/kg, a second dosage of 5 mg/kg, anda third dosage of 9 mg/kg.

The present invention further provides methods for treating infectiousdisease in a patient comprising administering a CTLA-4 antibody to thepatient according to a dosage escalation regimen, which includesadministering increasing dosages of the CTLA-4 antibody to the patientuntil an optimum dosage is reached.

In particular embodiments of the present invention, the CTLA-4 antibodyis a human sequence antibody. In a more particular embodiment, theCTLA-4 antibody is MDX-010, also referred to as ipilimumab. The MDX-010antibody comprises a heavy chain variable region that comprises CDR1,CDR2, and CDR3 domains; and a light chain variable region that comprisesCDR1, CDR2, and CDR3 domains, wherein the heavy chain variable regionCDR1 comprises amino acids having the sequence set forth in SEQ ID NO:1;the heavy chain variable region CDR2 comprises amino acids having thesequence set forth in SEQ ID N0:2; the heavy chain variable region CDR3comprises amino acids having the sequence set forth in SEQ ID NO:3; thelight chain variable region CDR1 comprises amino acids having thesequence set forth in SEQ ID NO:4; the light chain variable region CDR2comprises amino acids having the sequence set forth in SEQ ID NO:5; andthe light chain variable region CDR3 comprises amino acids having thesequence set forth in SEQ ID N0:6. The MDX-010 antibody comprises aheavy chain variable region comprising amino acids comprising thesequence set forth in SEQ ID NO:7. The MDX-010 antibody comprises alight chain variable region comprising amino acids comprising thesequence set forth in SEQ ID NO:8.

In embodiments of the present invention, a CTLA-4 antibody can beadministered according to a dosage escalation regimen in combinationwith a vaccine (e.g., gp100, tyrosinase or MART-1), a chemotherapeuticagent (e.g., cyclophosphamide or dacarbazine), or a cytokine (e.g.,IL-2).

DETAILED DESCRIPTION OF THE INVENTION

It has been surprisingly found that a patient receiving a CTLA-4antibody in an escalating dosage regimen according to the presentinvention can tolerate an optimum dose of the antibody. The methods ofthe present invention include dosage escalation regimens that permit apatient to tolerate a dosage of a CTLA-4 antibody that is about threetimes greater than previously reported maximum dosages. For example, thepresent invention provides a method for administering a 9 mg/kg dose ofa CTLA-4 antibody to a patient, and previous studies reported a maximumCTLA-4 antibody dose of 3 mg/kg (see, e.g., the clinical studiesdisclosed in U.S. Patent Publication No. 2004/0241169).

The methods of the present invention are based, in part, on the clinicalstudy summarized below and described further in the example.

In a clinical study, 46 HLA-A2 negative patients with progressive stageIV melanoma were treated with a CTLA-4 antibody according to a doseescalation regimen. Twenty-three patients started CTLA-4 antibodytherapy at 3 mg/kg and 23 patients started therapy at 5 mg/kg. Thepatients received progressively increased doses of the CTLA-4 antibodyuntil an objective clinical response was observed, a maximum of 9 mg/kgwas reached, or a grade III/IV autoimmune toxicity occurred. Fivepatients (11%) had an objective clinical response. Two of the responsesoccurred without grade III/IV autoimmune toxicity. One of the responsesoccurred without autoimmune toxicity. To date, four of the responses areongoing.

2.1. Escalating Dosage Regimens

The present invention includes methods for escalating the dosage of aCTLA-4 antibody administered to a patient until a partial or completeresponse is elicited in the patient, or a pre-determined maximum dosageis reached.

As used herein, a “complete response” means a complete disappearance ofa symptom or objective indicia of a disease. For example, a completeresponse in a patient with a tumor means the disappearance of allmeasurable lesions for greater than or equal to one month. For patientswith infectious diseases, a complete response means the completeclearance of the infectious toxin or pathogen from the patient (asmeasured by, e.g., a body fluid culture) or the complete resolution ofall signs and symptoms associated with the infectious disease (e.g.,fever, cough, leukocytosis).

As used herein, a “partial response” means a response that is less thana complete response. For example, a partial response in a patient with atumor is a decrease of approximately greater than or equal to 30% (butnot 100%) of the sum of the longest diameters of index (baseline)lesions, lasting at least one month with no growth of lesions or theappearance of new lesions. Tumor size can be measured directly or usingan imaging study (e.g., a CT, MRI, or sonogram). For infectiousdiseases, a partial response, means an improvement, but not completeresolution of, the signs and symptoms associated with the infectiousdisease or a decrease in the infectious toxin or pathogen in a patient(e.g., a decreased viral load in the case of HIV).

A “pre-determined maximum dosage” or a “pre-determined maximum dose” isa target endpoint dosage that is defined before the administration ofthe CTLA-4 dosage regimen. For example, prior to administration of thefirst dose of a CTLA-4 antibody to a patient, a clinician can identify 9mg/kg of the CTLA-4 antibody as the predetermined maximum dosage.

An “optimal” or “optimum” dose of a CTLA-4 antibody is the dosecorresponding to a predetermined maximum dose, or a dose that results ina partial or complete response to the disease being treated. It shall beappreciated by those of skill in the art that factors, including thepatient's immune state, which may be affected by prior immune therapies,disease state, age, etc., can impact the dosage required to elicit acomplete or partial response, or determine a pre-determined maximumdosage. A skilled clinician will be able to take such factors intoaccount when determining the initial dose, as well as any subsequentdoses, to obtain an optimum dosage. Typically, a CTLA-4 antibody dosageis about 0.1 mg/kg to about 25 mg/kg.

An “adverse event” (AE) as used herein is any unfavorable and generallyunintended, even undesirable, sign (including an abnormal laboratoryfinding), symptom, or disease associated with the use of a medicaltreatment (e.g., CTLA-4 antibody therapy). Most AE's are temporary andreverse upon withdrawal or reduction in dose of the medical treatment,or with treatment of the AE.

A “serious adverse event” (SAE) is a grade III or IV adverse event asdefined by the National Cancer Institute (NCI). A grade III AE isgenerally defined as “severe” and a grade IV AE is generally defined as“life-threatening or disabling”.

Adverse events associated with CTLA-4 antibody administration include:skin rash, vitiligo, hypophysitis, colitis, diarrhea, dermatitis,uveitis, nephritis, and increased liver enzymes. See also U.S. PatentPublication No. 2004/0241169 (the contents of which are herebyincorporated by reference in their entirety) for a description ofcertain adverse events associated with CTLA-4 antibody therapy. Anadverse event associated with CTLA-antibody therapy can limit, or causethe cessation of, the CTLA-4 antibody therapy.

As used herein, an “escalating dosage regimen” or “dosage escalationregimen” is a dosage regimen administered to a patient wherein dosagesin a series can be increased in a stepwise (i.e., a subsequent dosage iseither greater than or equal to the immediately preceding dosage, but atleast one increase in dosage occur over the length of the regimen) orlinear fashion (i.e., each subsequent dosage is greater than itsimmediately preceding dosage).

An initial dose of a CTLA-4 antibody is typically about 0.1 mg/kg toabout 10 mg/kg, and more typically about 3 mg/kg to about 10 mg/kg.Following an initial dose of CTLA-4 antibody, a patient is monitored bya clinician for a sufficient period of time, which is typically over thecourse of the dosage interval (e.g., 1 to 8 weeks, preferably 1 to 4weeks) to detect a partial or complete response. In the absence of apartial or complete response during the monitoring period, a second doseof CTLA-4 antibody can be administered that is greater than or equal tothe first dose. Following this second dose, the patient is againmonitored for a partial or complete response. Additional dosages greaterthan or equal to the immediately prior dose are administered in astepwise or linear fashion until a partial or complete response iselicited, or a pre-determined maximum dosage is obtained. If anadditional dose is required, the dosage can be increased by, e.g., about10% to about 100% of the immediately preceding dosage.

In one example of a linear dosage regimen, a patient is initiallyadministered about 3 mg/kg of a CTLA-4 antibody. If the patient does notachieve a partial or complete response after a 3 week period, then thepatient is administered about 5 mg/kg of CTLA-4 antibody.

In one example of a stepwise dosage regimen, a patient is initiallyadministered about 3 mg/kg of a CTLA-4 antibody followed by a seconddose of about CTLA-4 antibody at 3 mg/kg. Subsequent doses of CTLA-4antibody, in order, include about 5 mg/kg, about 5 mg/kg, about 9 mg/kg,and about 9 mg/kg. A dosage according to this example is administeredevery 3 weeks. The patient is monitored throughout the regimen todetermine whether a partial or complete response has been achieved. Ifthe patient does not achieve a partial or complete response before thenext scheduled dosage, the next scheduled dosage is administered. If thepatient does achieve a partial response, the patient is not given thenext scheduled dosage or is administered a dosage approximately equal tothe immediately preceding dosage.

2.2. General Definitions

Except when noted, the terms “patient” or “subject” are usedinterchangeably and refer to mammals such as human patients andnon-human primates, as well as experimental animals such as rabbits,rats, and mice, and other animals. Animals include all vertebrates,e.g., mammals and non-mammals, such as sheep, dogs, cows, chickens,amphibians, and reptiles.

The term “treating” includes the administration of CTLA-4 antibodies ofthe present invention to prevent or delay the onset of the symptoms,complications, or biochemical indicia of a disease, alleviating thesymptoms or arresting or inhibiting further development of the disease,condition, or disorder (e.g., cancer, an infectious disease, or anautoimmune disease). Treatment may be prophylactic (to prevent or delaythe onset of the disease, or to prevent the manifestation of clinical orsubclinical symptoms thereof) or therapeutic suppression or alleviationof symptoms after the manifestation of the disease.

The terms “about” or “approximately” mean within an acceptable range forthe particular parameter specified as determined by one of ordinaryskill in the art, which will depend in part on how the value is measuredor determined, e.g., the limitations of the measurement system. Forexample, “about” can mean a range of up to 20% of a given value.Alternatively, particularly with respect to biological systems orprocesses, the term can mean within an order of magnitude, preferablywithin 5-fold, and more preferably within 2-fold, of a value.

2.3. CTLA-4 Antibodies

The terms “cytotoxic T lymphocyte-associated antigen-4,” “CTLA-4,”“CTLA4,” “CTLA-4 antigen” and “CD 152” (see, e.g., Murata (1999) Am. J.Pathol. 155:453-460) are used interchangeably, and include variants,isoforms, species homologs of human CTLA-4, and analogs having at leastone common epitope with CTLA-4 (see, e.g., Balzano (1992) Int. J. CancerSuppl. 7:28-32). A complete sequence of human CTLA-4 is set forth inGenBank Accession No. L15006.

The term “epitope” means a protein determinant capable of specificbinding to an antibody. Epitopes usually consist of chemically activesurface groupings of molecules such as amino acids or sugar side chainsand usually have specific three dimensional structural characteristics,as well as specific charge characteristics. Conformational andnonconformational epitopes are distinguished in that the binding to theformer but not the latter is lost in the presence of denaturingsolvents.

An intact “antibody” comprises at least two heavy (H) chains and twolight (L) chains inter-connected by disulfide bonds. Each heavy chain iscomprised of a heavy chain variable region (abbreviated herein as HCVRor VH) and a heavy chain constant region. The heavy chain constantregion is comprised of three domains, CH1, CH2 and CH3. Each light chainis comprised of a light chain variable region (abbreviated herein asLCVR or VL) and a light chain constant region. The light chain constantregion is comprised of one domain, CL. The VH and VL regions can befurther subdivided into regions of hypervariability, termedcomplementarity determining regions (CDR), interspersed with regionsthat are more conserved, termed framework regions (FR). Each VH and VLis composed of three CDRs and four FRs, arranged from amino-terminus tocarboxyl-terminus in the following order: FR1, CDR1, FR2, CDR2, FR3,CDR3, FR4. The variable regions of the heavy and light chains contain abinding domain that interacts with an antigen. The constant regions ofthe antibodies may mediate the binding of the immunoglobulin to hosttissues or factors, including various cells of the immune system (e.g.,effector cells) and the first component (Clq) of the classicalcomplement system.

The term antibody includes antigen-binding portions of an intactantibody that retain capacity to bind CTLA-4. Examples of bindinginclude (i) a Fab fragment, a monovalent fragment consisting of the VL,VH, CL and CH1 domains; (ii) a F(ab′)2 fragment, a bivalent fragmentcomprising two Fab fragments linked by a disulfide bridge at the hingeregion; (iii) a Fd fragment consisting of the VH and CH1 domains; (iv) aFv fragment consisting of the VL and VH domains of a single arm of anantibody, (v) a dAb fragment (Ward et al., (1989) Nature 341:544-546),which consists of a VH domain; and (vi) an isolated complementaritydetermining region (CDR). Furthermore, although the two domains of theFv fragment, VL and VH, are coded for by separate genes, they can bejoined, using recombinant methods, by a synthetic linker that enablesthem to be made as a single protein chain in which the VL and VH regionspair to form monovalent molecules (known as single chain Fv (scFv); See,e.g., Bird et al., Science 1998; 242:423-426; and Huston et al., Proc.Natl. Acad. Sci. USA 1988; 85:5879-5883). Such single chain antibodiesare included by reference to the term “antibody.” Fragments can beprepared by recombinant techniques or enzymatic or chemical cleavage ofintact antibodies.

The term “human sequence antibody” includes antibodies having variableand constant regions (if present) derived from human germlineimmunoglobulin sequences. The human sequence antibodies of the inventionmay include amino acid residues not encoded by human germlineimmunoglobulin sequences (e.g., mutations introduced by random orsite-specific mutagenesis in vitro or by somatic mutation in vivo). Suchantibodies can be generated in non-human transgenic animals, i.e., asdescribed in PCT Publication Nos. WO 01/14424 and WO 00/37504. However,the term “human sequence antibody”, as used herein, is not intended toinclude antibodies in which CDR sequences derived from the germline ofanother mammalian species, such as a mouse, have been grafted onto humanframework sequences (i.e., humanized antibodies).

The terms “monoclonal antibody” or “monoclonal antibody composition”refer to a preparation of antibody molecules of single molecularcomposition. A monoclonal antibody composition displays a single bindingspecificity and affinity for a particular epitope. Accordingly, the term“human monoclonal antibody” refers to antibodies displaying a singlebinding specificity which have variable and constant regions (ifpresent) derived from human germline immunoglobulin sequences. In oneembodiment, the human monoclonal antibodies are produced by a hybridomawhich includes a B cell obtained from a transgenic non-human animal,e.g., a transgenic mouse, having a genome comprising a human heavy chaintransgene and a light chain transgene fused to an immortalized cell.

The term “polyclonal antibody” refers to a preparation of more than 1(two or more) different antibodies to human CTLA-4. Such a preparationincludes antibodies binding to a range of different epitopes.

CTLA-4 antibodies can bind to an epitope on human CTLA-4 so as toinhibit CTLA-4 from interacting with a human B7 counterreceptor. Becauseinteraction of human CTLA-4 with human B7 transduces a signal leading toinactivation of T-cells bearing the human CTLA-4 receptor, antagonism ofthe interaction effectively induces, augments or prolongs the activationof T cells bearing the human CTLA-4 receptor, thereby prolonging oraugmenting an immune response. CTLA-4 antibodies are described in U.S.Pat. Nos. 5,811,097, 5,855,887, 6,051,227, and 6,984,720; in PCTPublication Nos. WO 01/14424 and WO 00/37504; and in U.S. PublicationNo. 2002/0039581 and 2002/086014. Other anti-CTLA-4 antibodies that canbe used in a method of the present invention include, for example, thosedisclosed in: WO 98/42752; U.S. Pat. Nos. 6,682,736 and 6,207,156;Hurwitz et al., PNAS 1998; 95(17):10067-10071; Camacho et al., J ClinOncology 2004:22(145):abstract no. 2505 (antibody CP-675206); and Mokyr,et al., Cancer Research 1998; 58:5301-5304. Each of these references isspecifically incorporated herein by reference for purposes ofdescription of CTLA-4 antibodies. A preferred clinical CTLA-4 antibodyis human monoclonal antibody 10D1 (also referred to as MDX-010 andipilimumab and available from Medarex, Inc., Bloomsbury, N.J.) asdisclosed in WO 01/14424.

Also included in the invention are modified antibodies. The term“modified antibody” includes antibodies, such as monoclonal antibodies,chimeric antibodies, and humanized antibodies which have been modifiedby, e.g., deleting, adding, or substituting portions of the antibody.For example, an antibody can be modified by deleting the constant regionand replacing it with a constant region meant to increase half-life,e.g., serum half-life, stability or affinity of the antibody.

Antibody conjugates are also contemplated for use in the methods of thisinvention and can be used to modify a given biological response orcreate a biological response (e.g., to recruit effector cells). An“antibody conjugate,” as used herein, is a CTLA-4 antibody conjugated toa drug moiety. The drug moiety is not to be construed as limited toclassical chemical therapeutic agents. For example, the drug moiety maybe a protein or polypeptide possessing a desired biological activity.Such proteins may include, for example, an enzymatically active toxin,or active fragment thereof, such as abrin, ricin A, pseudomonasexotoxin, or diphtheria toxin; a protein such as tumor necrosis factoror interferon-alpha; or, biological response modifiers such as, forexample, lymphokines, interleukin-1 (“IL-1”), interleukin-2 (“1L-2”),interleukin-6 (“IL-6”), granulocyte macrophage colony stimulating factor(“GM-CSF”), granulocyte colony stimulating factor (“G-CSF”), or othergrowth factors.

2.4. Cancer Treatment

The present invention is directed, in part, to the treatment of tumors,particularly immunologically sensitive tumors, which are cancers thatrespond to immunotherapy or cancers that manifest in patients who areimmunocompromised. A tumor treated with the methods of this inventioncan be a solid tumor.

Examples of tumors that can be treated according to the inventioninclude sarcomas and carcinomas such as, but not limited to:fibrosarcoma, myxosarcoma, liposarcoma, chondrosarcoma, osteogenicsarcoma, chordoma, angiosarcoma, endotheliosarcoma, lymphangiosarcoma,lymphangioendotheliosarcoma, synovioma, mesothelioma, lymphoma,melanoma, Kaposi's sarcoma, Ewing's tumor, leiomyosarcoma,rhabdomyosarcoma, colo-rectal carcinoma, gastric carcinoma, pancreaticcancer, breast cancer, ovarian cancer, prostate cancer, squamous cellcarcinoma, basal cell carcinoma, adenocarcinoma, sweat gland carcinoma,sebaceous gland carcinoma, papillary carcinoma, papillaryadenocarcinomas, cystadenocarcinoma, medullary carcinoma, bronchogeniccarcinoma, renal cell carcinoma, hepatoma, bile duct carcinoma,choriocarcinoma, seminoma, embryonal carcinoma, Wilms' tumor, cervicalcancer, testicular tumor, lung carcinoma, small cell lung carcinoma,bladder carcinoma, epithelial carcinoma, glioma, astrocytoma,medulloblastoma, craniopharyngioma, ependymoma, pinealoma,hemangioblastoma, acoustic neuroma, oligodendroglioma, meningioma,melanoma, neuroblastoma, and retinoblastoma.

The methods of this invention can also treat or prevent dysproliferativechanges (such as metaplasias and dysplasias) in epithelial tissues suchas those in the cervix, esophagus, and lung. Thus, the present inventionprovides for treatment of conditions known or suspected of precedingprogression to neoplasia or cancer, in particular, where non-neoplasticcell growth consisting of hyperplasia, metaplasia, or most particularly,dysplasia has occurred (for review of such abnormal growth conditions,see Robbins and Angell, 1976, Basic Pathology, 2d Ed., W.B. SaundersCo., Philadelphia, pp. 68-79). Hyperplasia is a form of controlled cellproliferation involving an increase in cell number in a tissue or organ,without significant alteration in structure or function. As but oneexample, endometrial hyperplasia often precedes endometrial cancer.Metaplasia is a form of controlled cell growth in which one type ofadult or fully differentiated cell substitutes for another type of adultcell. Metaplasia can occur in epithelial or connective tissue cells.Atypical metaplasia involves a somewhat disorderly metaplasticepithelium. Dysplasia is frequently a forerunner of cancer, and is foundmainly in the epithelia; it is the most disorderly form ofnon-neoplastic cell growth, involving a loss in individual celluniformity and in the architectural orientation of cells. Dysplasticcells often have abnormally large, deeply stained nuclei, and exhibitpleomorphism. Dysplasia characteristically occurs where there existschronic irritation or inflammation, and is often found in the cervix,respiratory passages, oral cavity, and gall bladder. For a review ofsuch disorders, see Fishman et al., 1985, Medicine, 2d Ed., J. B.Lippincott Co., Philadelphia.

The present invention is also directed to treatment of non-malignanttumors and other disorders involving inappropriate cell or tissue growthaugmented by angiogenesis by administering a therapeutically effectiveamount of a vector of the invention to the tissue undergoinginappropriate growth. For example, it is contemplated that the inventionis useful for the treatment of arteriovenous (AV) malformations,particularly in intracranial sites. The invention may also be used totreat psoriasis, a dermatologic condition that is characterized byinflammation and vascular proliferation; and benign prostatichypertrophy, a condition associated with inflammation and possiblyvascular proliferation. Treatment of other hyperproliferative disordersis also contemplated.

The term “advanced cancer” means cancer that is no longer localized tothe primary tumor site, or a cancer that is Stage III or IV according tothe American Joint Committee on Cancer (AJCC).

2.5. Treatment of Infectious Disease

Other methods of the invention are used to treat patients that have beenexposed to pathogens. Similar to its application to tumors as discussedabove, CTLA-4 antibody administered according to a dosage escalationregimen of the present invention can be used alone, or in combinationwith a vaccine to treat an infectious disease. CTLA-4 blockade has beenshown to be effective in the acute phase of infections ofNippostrongylus brasiliensis (McCoy, K. et al. (1997) 186(2); 183-187)and Leishmania donovani (Murphy, M. et al. (1998) J. Immunol.161:4153-4160). Examples of pathogens for which this therapeuticapproach may be particularly useful include pathogens for which there iscurrently no effective vaccine, or pathogens for which conventionalvaccines are less than completely effective. These include, but are notlimited to HIV, Hepatitis (A, B, & C), Influenza, Herpes, Giardia,Malaria, Leishmania, Staphylococcus aureus, and Pseudomonas aeruginosa.CTLA-4 blockade is particularly useful in boosting immunity againstestablished infections by agents such as HIV that present alteredantigens over the course of the infections. These novel epitopes arerecognized as foreign at the time of anti-human CTLA-4 administration,thus provoking a strong T-cell response that is not dampened by negativesignals through CTLA-4.

Some examples of pathogenic viruses causing infections treatable bymethods of the invention include hepatitis (A, B, or C), herpes virus(e.g., VZV, HSV-1, HAV-6, HSV-II, and CMV, Epstein Barr virus),adenovirus, influenza virus, flaviviruses, echovirus, rhinovirus,coxsackie virus, cornovirus, respiratory syncytial virus, mumps virus,rotavirus, measles virus, rubella virus, parvovirus, vaccinia virus,HTLV virus, dengue virus, papillomavirus, molluscum virus, poliovirus,rabies virus, JC virus and arboviral encephalitis virus.

Some examples of pathogenic bacteria causing infections treatable bymethods of the invention include chlamydia, rickettsial bacteria,mycobacteria, staphylococci, streptococci, pneumonococci, meningococciand conococci, klebsiella, proteus, serratia, pseudomonas, legionella,diphtheria, salmonella, bacilli, cholera, tetanus, botulism, anthrax,plague, leptospirosis, and Lyme disease bacteria.

Some examples of pathogenic fungi causing infections treatable bymethods of the invention include Candida (albicans, krusei, glabrata,tropicalis, etc.), Cryptococcus neoformans, Aspergillus (fumigants,niger, etc.), Genus Mucorales (Mucor, Absidia, Rhizophus), Sporothrixschenkii, Blastomyces dermatitidis, Paracoccidioides brasiliensis,Coccidioides immitis and Histoplasma capsulatum.

Some examples of pathogenic parasites causing infections treatable bymethods of the invention include Entamoeba histolytica, Balantidiumcoli, Naegleria fowleri, Acanthamoeba sp., Giardia lambia,Cryptosporidium sp., Pneumocystis carinii, Plasmodium vivax, Babesiamicroti, Trypanosoma brucei, Trypanosoma Leishmania donovani, Toxoplasmagondi, Nippostrongylus brasiliensis.

2.6. Treatment for the Inappropriate Accumulation of Self-Antigens

A CTLA-4 antibody can be administered according to a dosage escalationregimen of the present invention to treat a patient having aninappropriate accumulation of self-antigens, such as amyloid deposits,cytokines such as TNFα, and IgE (for the treatment of allergy andasthma). For example, Alzheimer's disease involves inappropriateaccumulation of Aβ peptide in amyloid deposits in the brain; antibodyresponses against amyloid are able to clear these amyloid deposits(Schenk et al., Nature 1999; 400:173-177).

2.7. Combination Treatments 2.7.1. CTLA-4 Antibodies and Vaccines forthe Treatment of Cancer

According to the methods of the present invention, a CTLA-4 antibody canbe administered in a dosage escalation regimen alone or in combinationwith one or more other therapeutic agents, or in conjunction with aninimunotherapeutic vaccine for the tumor, such as chemotherapy,radiation therapy, cytokines, chemokines and other biologic signalingmolecules, tumor specific vaccines, autologous and allogeneic stem cellrescue (e.g., to augment graft versus tumor effects), other therapeuticantibodies, molecular targeted therapies, anti-angiogenic therapy,infectious agents with therapeutic intent (such as tumor localizingbacteria), and gene therapy. The antibodies can be used in adjuvant orneoadjuvant therapy, either alone or in conjunction with theaforementioned therapies.

Antibodies to CTLA-4 can be combined with an immunogenic agent, such ascancerous cells, purified tumor antigens (including recombinantproteins, peptides, and carbohydrate molecules), cells, and cellstransfected with genes encoding immune stimulating cytokines and cellsurface antigens such as B7 (see, e.g., Hurwitz, A. et al. (1998) Proc.Natl. Acad. Sci U.S.A. 1998; 95:10067-10071), or used alone, tostimulate immunity.

Treatment with a CTLA-4 antibody can be used to activate a pre-existingmemory response in patients treated with a cancer vaccine. Thus, methodsof this invention include treating vaccine-treated patients who areselected for further treatment with a CTLA-4 antibody to thereby furtherinduce or enhance an immune response.

Many experimental strategies for vaccination against tumors have beendevised (see Rosenberg, S., 2000, Development of Cancer Vaccines, ASCOEducational Book Spring: 60-62; Logothetis, C., 2000, ASCO EducationalBook Spring: 300-302; Khayat, D. 2000, ASCO Educational Book Spring:414-428; Foon, K. 2000, ASCO Educational Book Spring: 730-738; see alsoRestifo, N. and Sznol, M., Cancer Vaccines, Ch. 61, pp. 3023-3043 inDeVita, V. et al. (eds.), 1997, Cancer: Principles and Practice ofOncology, Fifth Edition). In one of these strategies, a vaccine isprepared using autologous or allogeneic tumor cells. These cellularvaccines have been shown to be most effective when the tumor cells aretransduced to express GM-CSF. GM-CSF has been shown to be a potentactivator of antigen presentation for tumor vaccination (Dranoff et al.Proc. Natl. Acad. Sci U.S.A. 1993; 90: 3539-43).

CTLA-4 blockade to boost GMCSF-modified tumor cell vaccines improvesefficacy of vaccines in a number of experimental tumor models such asmammary carcinoma (Hurwitz et al., 1998, supra), primary prostate cancer(Hurwitz et al., Cancer Research 2000; 60:2444-8) and melanoma (vanElsas et al. J. Exp. Med. 1999, 190:355-66). In these instances,non-immunogenic tumors, such as the B16 melanoma, have been renderedsusceptible to destruction by the immune system. The tumor cell vaccinemay also be modified to express other immune activators such as IL-2,and costimulatory molecules, among others.

The study of gene expression and large scale gene expression patterns invarious tumors has led to the definition of so called “tumor specificantigens” (Rosenberg, Immunity 1999; 10:281-7). In many cases, thesetumor specific antigens are differentiation antigens expressed in thetumors and in the cell from which the tumor arose, for examplemelanocyte antigens gp100, MAGE, and Trp-2. More importantly, many ofthese antigens can be shown to be the targets of tumor specific T-cellsfound in the host. CTLA-4 blockade may be used as a boosting agent inconjunction with vaccines based on recombinant versions of proteinsand/or peptides found to be expressed in a tumor. The tumor antigen mayalso include the protein telomerase, which is required for the synthesisof telomeres of chromosomes and which is expressed in more than 85% ofhuman cancers and in only a limited number of somatic tissues (Kim etal., Science 1994; 266:2011-2013). These somatic tissues may beprotected from immune attack by various means.

Tumor antigen may also be “neo-antigens” expressed in cancer cellsbecause of somatic mutations that alter protein sequence or createfusion proteins between two unrelated sequences (i.e. bcr-abl in thePhiladelphia chromosome), or idiotype from B-cell tumors. Other tumorvaccines may include the proteins from viruses implicated in humancancers such a Human Papilloma Viruses (HPV), Hepatitis Viruses (HBV andHCV) and Kaposi's Herpes Sarcoma Virus (KHSV). Another form of tumorspecific antigen which may be used in conjunction with CTLA-4 blockadeis purified heat shock proteins (HSP) isolated from the tumor tissueitself. These heat shock proteins contain fragments of proteins from thetumor cells and these HSPs are highly efficient at delivery to antigenpresenting cells for eliciting tumor immunity (Snot and Srivastava,Science 1995; 269:1585-1588; Tamura et al., Science 1997, 278:117-120).

Dendritic cells (DC) are potent antigen presenting cells that can beused to prime antigen-specific responses. DC's can be produced ex vivoand loaded with various protein and peptide antigens as well as tumorcell extracts (Nestle et al., Nature Medicine 1998; 4:328-332). DCs mayalso be transduced by genetic means to express these tumor antigens aswell. DCs have also been fused directly to tumor cells for the purposesof immunization (Kugler et al., Nature Medicine 2000; 6:332-336). As amethod of vaccination, DC immunization may be effectively boosted withCTLA-4 blockade according to a dosage escalation regimen of the presentinvention to activate more potent anti-tumor responses.

Another type of melanoma vaccine that can be combined with CTLA-4blockade according to the present invention is a vaccine prepared from amelanoma cell line lysate, in conjunction with an immunologicaladjuvant, such as the MELACINE® vaccine, a mixture of lysates from twohuman melanoma cell lines plus DETOX™ immunological adjuvant. Vaccinetreatment can be boosted with CTLA-4 antibody, with or withoutadditional chemotherapeutic treatment.

2.7.2. Chemotherapeutic Agents and Other Standard Cancer Treatments

CTLA-4 administration in a dosage escalation regimen according to thepresent invention can be used in combination with standard cancertreatments. In these instances, it may be possible to reduce the dose ofchemotherapeutic reagent administered (Mokyr et al., Cancer Research,1998; 58:5301-5304). The scientific rationale behind the combined use ofCTLA-4 blockade and chemotherapy is that cell death, that is aconsequence of the cytotoxic action of most chemotherapeutic compounds,should result in increased levels of tumor antigen in the antigenpresentation pathway. Thus, CTLA-4 can boost an immune response primedto chemotherapy release of tumor cells. Moreover, the immuno-stimulatoryactivity of CTLA-4 is useful to overcome the immunosuppressive effectsof chemotherapy. Examples of chemotherapeutic agents with which CTLA-4treatment can be combined include, but are not limited to, aldesleukin,altretamine, amifostine, asparaginase, bleomycin, capecitabine,carboplatin, carmustine, cladribine, cisapride, cisplatin,cyclophosphamide, cytarabine, dacarbazine (DTIC), dactinomycin,docetaxel, doxorubicin, dronabinol, epoetin alpha, etoposide,filgrastim, fludarabine, fluorouracil, gemcitabine, granisetron,hydroxyurea, idarubicin, ifosfamide, interferon alpha, irinotecan,lansoprazole, levamisole, leucovorin, megestrol, mesna, methotrexate,metoclopramide, mitomycin, mitotane, mitoxantrone, omeprazole,ondansetron, paclitaxel (TAXOL®), pilocarpine, prochloroperazine,rituximab, tamoxifen, topotecan hydrochloride, trastuzumab, vinblastine,vincristine and vinorelbine tartrate. For prostate cancer treatment, apreferred chemotherapeutic agent with which CTLA-4 can be combined ispaclitaxel (TAXOL®). For melanoma cancer treatment, a preferredchemotherapeutic agent with which CTLA-4 can be combined is dacarbazine(DTIC).

Other combination therapies that may result in immune system primingthrough cell death are radiation, surgery, and hormone deprivation(Kwon, E. et al. Proc. Natl. Acad. Sci U.S.A. 1999; 96 (26): 15074-9.Each of these protocols creates a source of tumor antigen in the host.For example, any manipulation of the tumor at the time of surgery cangreatly increase the number of cancer cells in the blood (Schwartz, etal., Principles of Surgery 1984. 4^(th) ed. p.338). Angiogenesisinhibitors may also be combined with a CTLA-4 antibody dosage escalationregimen. Inhibition of angiogenesis leads to tumor cell death which mayfeed tumor antigen into host antigen presentation pathways.

2.7.3. Cytokines

A CTLA-4 antibody administered in a dosage escalation regimen accordingto the present invention can also be combined with other forms ofimmunotherapy such as cytokine treatment (e.g., interferons, GMCSF,GCSF, IL-2, or bispecific antibody therapy, which provides for enhancedpresentation of tumor antigens (see e.g., Holliger (1993) Proc. Natl.Acad. Sci. USA 90:6444-6448; Poljak (1994) Structure 2:1121-1123).

Typical dosages regimens for cytokines include 720,000 IU/kg/dose every8 hours for up to 15 doses per dosage of CTLA-4 antibody.

2.8. Pharmaceutical Compositions and Routes of Administration

The invention encompasses pharmaceutical compositions comprising aCTLA-4 human monoclonal antibody and/or a human sequence CTLA-4 antibody(intact or binding fragments) formulated together with apharmaceutically acceptable carrier for use in a dosage escalationregimen. Some compositions include a combination of multiple (e.g., twoor more) isolated human CTLA-4 antibodies and/or human sequence antibodyor antigen-binding portions thereof of the invention.

Pharmaceutically acceptable carriers include solvents, dispersion media,coatings, antibacterial and antifungal agents (e.g., paraben,chlorobutanol, phenol sorbic acid, and the like), isotonic andabsorption delaying agents, and the like that are physiologicallycompatible. The carrier can be suitable for intravenous, intramuscular,subcutaneous, parenteral, spinal or epidermal administration (e.g., byinjection or infusion). Depending on the route of administration, theactive compound, i.e., antibody, bispecific and multispecific molecule,may be coated in a material to protect the compound from the action ofacids and other natural conditions that may inactivate the compound.

Pharmaceutically acceptable carriers also include sterile aqueoussolutions or dispersions and sterile powders for the extemporaneouspreparation of sterile injectable solutions or dispersion. The use ofsuch media and agents for pharmaceutically active substances is known inthe art. Except insofar as any conventional media or agent isincompatible with the active compound, use thereof in the pharmaceuticalcompositions of the invention is contemplated. For example, the compoundmay be administered to a subject in an appropriate carrier, for example,liposomes, or a diluent. Pharmaceutically acceptable diluents includesaline and aqueous buffer solutions. Liposomes includewater-in-oil-in-water CGF emulsions as well as conventional liposomes(Strejan et al. (1984) J. Neuroimmunol. 7:27). Supplementary activecompounds can also be incorporated into the compositions.

Therapeutic compositions typically must be sterile, substantiallyisotonic, and stable under the conditions of manufacture and storage.The composition can be formulated as a solution, microemulsion,liposome, or other ordered structure suitable to high drugconcentration. The carrier can be a solvent or dispersion mediumcontaining, for example, water, ethanol, polyol (for example, glycerol,propylene glycol, and liquid polyethylene glycol, and the like), andsuitable mixtures thereof, vegetable oils, such as olive oil, andinjectable organic esters, such as ethyl oleate. The proper fluidity canbe maintained, for example, by the use of a coating such as lecithin, bythe maintenance of the required particle size in the case of dispersionand by the use of surfactants. In many cases, it is preferable toinclude isotonic agents, for example, sugars, polyalcohols such asmannitol, sorbitol, or sodium chloride in the composition. Prolongedabsorption of the injectable compositions can be brought about byincluding in the composition an agent that delays absorption, forexample, monostearate salts and gelatin. These compositions may alsocontain adjuvants such as preservatives, wetting agents, emulsifyingagents and dispersing agents.

Sterile injectable solutions can be prepared by incorporating the activecompound in the required amount in an appropriate solvent with one or acombination of ingredients enumerated above, as required, followed bysterilization microfiltration. Generally, dispersions are prepared byincorporating the active compound into a sterile vehicle that contains abasic dispersion medium and the required other ingredients from thoseenumerated above. In the case of sterile powders for the preparation ofsterile injectable solutions, the preferred methods of preparation arevacuum drying and freeze-drying (lyophilization) that yield a powder ofthe active ingredient plus any additional desired ingredient from apreviously sterile-filtered solution thereof.

A “pharmaceutically acceptable salt” refers to a salt that retains thedesired biological activity of the parent compound and does not impartany undesired toxicological effects (See e.g., Berge, S. M., et al.(1977) J. Pharm. Sci. 66:1-19). Examples of such salts include acidaddition salts and base addition salts. Acid addition salts includethose derived from nontoxic inorganic acids, such as hydrochloric,nitric, phosphoric, sulfuric, hydrobromic, hydroiodic, phosphorous andthe like, as well as from nontoxic organic acids such as aliphatic mono-and dicarboxylic acids, phenyl-substituted alkanoic acids, hydroxyalkanoic acids, aromatic acids, aliphatic and aromatic sulfonic acidsand the like. Base addition salts include those derived from alkalineearth metals, such as sodium, potassium, magnesium, calcium and thelike, as well as from nontoxic organic amines, such asN,N′-dibenzylethylenediamine, N-methylglucamine, chloroprocaine,choline, diethanolamine, ethylenediamine, procaine and the like.

A composition for use in a dosage escalation regimen according to thepresent invention can be administered by a variety of methods known inthe art. The route and/or mode of administration vary depending upon thedesired results. The active compounds can be prepared with carriers thatprotect the compound against rapid release, such as a controlled releaseformulation, including implants, transdermal patches, andmicroencapsulated delivery systems. Biodegradable, biocompatiblepolymers can be used, such as ethylene vinyl acetate, polyanhydrides,polyglycolic acid, collagen, polyorthoesters, and polylactic acid. Manymethods for the preparation of such formulations are described by e.g.,Sustained and Controlled Release Drug Delivery Systems, J. R. Robinson,ed., Marcel Dekker, Inc., New York, 1978. In addition, prolongedabsorption of an injectable pharmaceutical form may be brought about bythe inclusion of agents which delay absorption such as aluminummonostearate and gelatin. Pharmaceutical compositions are preferablymanufactured under GMP conditions.

Examples of pharmaceutically-acceptable antioxidants for use inpharmaceutical compositions include: (1) water soluble antioxidants,such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodiummetabisulfite, sodium sulfite and the like; (2) oil-solubleantioxidants, such as ascorbyl palmitate, butylated hydroxyanisole(BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate,alpha-tocopherol, and the like; and (3) metal chelating agents, such ascitric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaricacid, phosphoric acid, and the like.

For the therapeutic compositions, formulations for use in the methods ofthe present invention include those suitable for oral, nasal, topical(including buccal and sublingual), rectal, vaginal and/or parenteraladministration. The formulations can conveniently be presented in unitdosage form and may be prepared by any methods known in the art ofpharmacy. The amount of active ingredient which can be combined with acarrier material to produce a single dosage form varies depending uponthe subject being treated, and the particular mode of administration.Generally, out of one hundred percent, this amount ranges from about0.01 percent to about ninety-nine percent of active ingredient, fromabout 0.1 percent to about 70 percent, or from about 1 percent to about30 percent.

Formulations of the present invention which are suitable for vaginaladministration also include pessaries, tampons, creams, gels, pastes,foams or spray formulations containing such carriers as are known in theart to be appropriate. Dosage forms for the topical or transdermaladministration of compositions of this invention include powders,sprays, ointments, pastes, creams, lotions, gels, solutions, patches andinhalants. The active compound may be mixed under sterile conditionswith a pharmaceutically acceptable carrier, and with any preservatives,buffers, or propellants which may be required.

The phrases “parenteral administration” and “administered parenterally”mean modes of administration other than enteral and topicaladministration, usually by injection, and includes, without limitation,intravenous, intramuscular, intraarterial, intrathecal, intracapsular,intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal,subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid,intraspinal, epidural and intrasternal injection and infusion.

Therapeutic compositions can be administered with medical devices knownin the art. For example, in a preferred embodiment, a therapeuticcomposition of the invention can be administered with a needlelesshypodermic injection device, such as the devices disclosed in, e.g.,U.S. Pat. Nos. 5,399,163, 5,383,851, 5,312,335, 5,064,413, 4,941,880,4,790,824, or 4,596,556. Examples of implants and modules useful in thepresent invention include: U.S. Pat. No. 4,487,603, which discloses animplantable micro-infusion pump for dispensing medication at acontrolled rate; U.S. Pat. No. 4,486,194, which discloses a therapeuticdevice for administering medicants through the skin; U.S. Pat. No.4,447,233, which discloses a medication infusion pump for deliveringmedication at a precise infusion rate; U.S. Pat. No. 4,447,224, whichdiscloses a variable flow implantable infusion apparatus for continuousdrug delivery; U.S. Pat. No. 4,439,196, which discloses an osmotic drugdelivery system having multi-chamber compartments; and U.S. Pat. No.4,475,196, which discloses an osmotic drug delivery system. Many othersuch implants, delivery systems, and modules are known.

Some human sequence antibodies and human monoclonal antibodies of theinvention can be formulated to ensure proper distribution in vivo. Forexample, the blood-brain barrier (BBB) excludes many highly hydrophiliccompounds. To ensure that the therapeutic compounds of the inventioncross the BBB (if desired), they can be formulated, for example, inliposomes. For methods of manufacturing liposomes, See, e.g., U.S. Pat.Nos. 4,522,811; 5,374,548; and 5,399,331. The liposomes may comprise oneor more moieties which are selectively transported into specific cellsor organs, thus enhance targeted drug delivery (See, e.g., V. V. Ranade(1989) J. Clin. Pharmacol. 29:685). Exemplary targeting moieties includefolate or biotin (See, e.g., U.S. Pat. No. 5,416,016 to Low et al.);mannosides (Umezawa et al., (1988) Biochem. Biophys. Res. Commun.153:1038); antibodies (P. G. Bloeman et al. (1995) FEBS Lett. 357:140;M. Owais et al. (1995) Antimicrob. Agents Chemother. 39:180); surfactantprotein A receptor (Briscoe et al. (1995) Am. J. Physiol. 1233:134),different species of which may comprise the formulations of theinventions, as well as components of the invented molecules; p120(Schreier et al. (1994) J. Biol. Chem. 269:9090); See also K. Keinanen;M. L. Laukkanen (1994) FEBS Lett. 346:123; J. J. Killion; I. J. Fidler(1994) Immunomethods 4:273. In some methods, the therapeutic compoundsof the invention are formulated in liposomes; in a more preferredembodiment, the liposomes include a targeting moiety. In some methods,the therapeutic compounds in the liposomes are delivered by bolusinjection to a site proximal to the tumor or infection. The compositionshould be fluid to the extent that easy syringability exists. It shouldbe stable under the conditions of manufacture and storage and should bepreserved against the contaminating action of microorganisms such asbacteria and fungi.

The present invention is further described by way of the followingparticular examples. However, the use of such examples is illustrativeonly and is not intended to limit the scope or meaning of the presentinvention or of any exemplified term. Furthermore, the present inventionis not limited to any particular preferred embodiments) describedherein. Indeed, many modifications and variations of the invention willbe apparent to those skilled in the art upon reading this specification,and such “equivalents” can be made without departing from the inventionin spirit or scope. The invention is therefore limited only by the termsof the appended claims, along with the full scope of equivalents towhich the claims are entitled.

EXAMPLE 1 Intra-Patient Dose Escalation of CTLA-4 Antibody in Patientswith Metastatic Melanoma

Forty-six HLA-A2 negative patients with progressive stage IV melanomawere treated using a CTLA-4 antibody dose escalation regimen to testwhether higher doses of CTLA-4 antibody would induce increasedautoimmunity and concomitant tumor regression. Twenty-three patientsstarted CTLA-4 antibody administration at 3 mg/kg and 23 patientsstarted treatment at 5 mg/kg. Each group was administered a dose everythree weeks. Patients were administered the CTLA-4 antibody according tothe dosage escalation regimen to a predetermined maximum dose of 9 mg/kgor until objective clinical responses or grade III/IV autoimmunetoxicity was observed.

2.9. Methods 2.9.1. Patients and Treatment

Patients eligible for treatment with CTLA-4 antibody (MDX-010, MedarexInc., Bloomsbury, N.J.) were HLA-A*0201⁻, had measurable stage IVmelanoma, were at least 16 years of age, had a life expectancy of atleast six months, an ECOG Performance Status≦2, and at least 3 weeks hadelapsed since any systemic cancer therapy had been administered.Patients were excluded if they had autoimmune disease, active infection,were pregnant or nursing, had any concurrent medical condition requiringthe use of systemic or topical steroids, or had received prior treatmentwith CTLA-4 antibody. All patients were treated on an InvestigationalReview Board approved protocol in the Surgery Branch, National CancerInstitute in Bethesda, Md.

At the initial patient screening, patients underwent a physicalexamination, assessment of performance status, ophthalmologicexamination, ECG, pulmonary function tests, HLA typing, pheresis,rheumatoid factor, antinuclear antibody, human anti-human antibody(HAHA), hematologic, biochemical, and thyroid function tests. Afterevery dose cycle, a physical exam and thyroid, hematologic, andbiochemical panels were performed. Diagnostic imaging, an autoimmunepanel, urinalysis, pheresis, and HAHA were obtained after every course,and a repeat ophthalmologic exam was performed after 4 cycles or asclinically indicated.

CTLA-4 antibody was administered to each patient in escalating dosesuntil the development of an objective response (partial or complete),the predetermined maximum dose (i.e., 9 mg/kg) was reached, or a≧gradeIII autoimmune or another dose-limiting toxicity was observed. In thefirst 23 patients the starting dose of MDX-010 was 3 mg/kg, (this wasalso the initial dose reported in Attia et al., 2005 Sep. 1;23(25):6043-53. Epub 2005 Aug. 8; and Phan et al., PNAS 2003,100:8372-8377). Subsequent doses were escalated to 5 mg/kg, and then to9 mg/kg. For the next 23 patients, the starting dose of CTLA-4 antibodywas 5 mg/kg. A cycle was defined as one dose administration, and acourse was defined as the administration of two doses at the same drugconcentration.

Blood samples were drawn immediately prior to each dose cycle and againone hour post antibody infusion. Quantitative ELISA was used todetermine plasma concentrations of CTLA-4 antibody as previouslydescribed. Briefly, microtiter plates were coated with recombinant humanCTLA-4-1g and bound CTLA-4 antibody was detected with an alkalinephosphatase labeled goat anti-human IgG probe. Phenotypic analysis ofT-cell activation markers was performed using standard flow analysistechniques by Esoterix Inc. (East Windsor, N.J.) on peripheral bloodsamples obtained immediately prior to each course.

After completion of a course at a given dose, patients who did notexperience an objective response or dose-limiting toxicity wereescalated to the next dose level. Patients who experienced a completeresponse were treated for two additional cycles at the same dose level.Patients who achieved a partial response, and continued to have tumorregression, were re-treated at the same dose level until they achieved acomplete response or no longer had tumor shrinkage. Once a patientexperienced a complete response or the tumor size stabilized, theyreceived two additional cycles at the same dose level. Patients whocompleted treatment with two cycles of antibody at each dose level,either 3 mg/kg, 5 mg/kg, and 9 mg/kg (patients 1-23), or 5 mg/kg and 9mg/kg (patients 24-46), and had stable disease at follow-up evaluationwere eligible to receive one additional course at 9 mg/kg. However, ifthese patients demonstrated progressive disease they were taken off ofthe study.

Patients who experienced non-skin related≧grade III adverse events, anyautoimmune ocular toxicity, or required steroid therapy for toxicityattributable to CTLA-4 antibody administration did not receive furthertherapy, regardless of their clinical response status. Patients thatexperienced skin-related toxicity≦grade III, or a non-skin relatedtoxicity<grade III may have had their antibody administration delayed.

The human IgGlκ CTLA-4 MDX-010 monoclonal antibody was administered asan intravenous bolus over 90 minutes every three weeks. Prior toantibody administration and, when possible, three weeks after eachcourse, peripheral blood mononuclear cells (PBMC) were obtained byapheresis, isolated by Ficoll-Hypaque separation, and cryopreserved at−180 degrees Celsius in heat-inactivated human AB serum with 10% DMSOuntil further use.

2.9.2. Clinical Response Evaluation and On-Study Evaluation

All patients underwent computed axial tomography of the chest, abdomen,and pelvis, and MRI of the brain, within 28 days of starting treatmentand after every two cycles of treatment. RECIST criteria were utilizedto determine radiographic response to treatment (Therasse et al., J NatlCancer Inst 2000, 92:205-216). The sum of the longest diameters of alltumors before and after therapy was calculated. A partial response wasdefined as a decrease of greater than or equal to 30% (but not 100%) ofthe sum of the longest diameters of index lesions, lasting at least onemonth with no growth of lesions or the appearance of new lesions. Acomplete response was defined as the disappearance of all lesions forgreater than or equal to one month. Patients not achieving either apartial or complete response were deemed non-responders.

Forty-six HLA-A2 negative patients had stage IV melanoma with metastasesto various sites (Table 1). Thirty-nine patients (85%) had visceralmetastases. Thirty-two patients (70%) were male. Patients receivedtreatment prior to enrollment in this study as follows: 29 (63%) hadreceived chemotherapy, 14 (30%) radiation therapy, 2 (4%) hormonaltherapy, 38 (83%) immunotherapy, and 28 (61%) had received more than onetherapy. Patients 1-23 began treatment with CTLA-4 antibody at aconcentration of 3 mg/kg and patients 24-46 started at a concentrationof 5 mg/kg.

Treatment, autoimmunity, and response characteristics for patientstreated with CTLA-4 antibody are summarized in Table 1.

TABLE 1 Patient characteristics, clinical response, and toxicity PriorResponse Autoimmune Toxicity Age Sex Disease Sites Therapy Doses (mg/kg)(mo.)* (Grade III/IV)** 1 47 M Mesenteric LN S, I 3, 3, 3, 3, 5, 5, 9,9, 9, 9 PR (12+) hypophysitis 2 50 M Cervical LN, lung, SQ S, C, I 3, 3NR 3 43 M Adrenal, ALN, lung S, C, I 3, 3, 5, 5, 9, 9, 9 NR hypophysitis4 66 M lung S, I 3, 3, 5, 5, 9, 9, 9, 9, 9, 9 PR (12+) 5 30 M lung S, I3, 3, 5, 5, 9 NR hypophysitis 6 27 F ALN, brain, lung, R, S, I 3, 3 NRRPLN, SQ, supraclavicular LN 7 48 M aortic LN, periportal LN, S, C, I 3,3, 5, 5, 9, 9, 9, 9, 9, 9 PR (11+) RPLN 8 33 F clavicular LN, liver, S,I 3, 3, 5, 5 NR lung, MLN, mandibular LN, muscle 9 43 M ALN, MLN, liver,lung, S, C, I 3, 3, 5, 5, 9, 9 NR periaortic LN, spleen, SQ 10 61 Mlung, muscle S, C, H, I 3, 3, 5, 5, 9, 9 PR (9) hypophysitis 11 34 Mlung S, I 3, 3, 5, 5 NR 12 43 M Iliac LN, periaortic LN S, I 3, 3, 5, 5,9, 9 NR anterior uveitis 13 63 M lung, MLN S, C, I 3, 3 NR 14 68 M MLN,SQ R, S, C, I 3, 3, 5, 5, 9, 9 NR 15 56 F bone, gallbladder, lung, R, S3 NR dermatitis muscle, popliteal LN, SQ 16 52 F lung S, C, I 3, 3, 5,5, 9, 9 NR 17 35 F adrenal, mesenteric LN, S, C, I 3, 3, 5, 5, 9, 9, 9,9 NR pelvis, RPLN 18 35 M liver, pelvis, SQ, spleen S, C, I 3, 3, 5 NRtubulointerstitial nephritis 19 38 M bone, MLN, parotid, SQ R, S, I 3 NR20 66 M lung, MLN R, S, I 3, 3, 5, 5, 9, 9 NR 21 44 F iliac LN, liver,lung, S, I 3, 3, 5, 5 NR arthritis MLN, periaortic LN 22 64 M bone,liver, lung, MLN, S, C, I 3.3, 5, 5, 9, 9 NR SQ 23 48 M iliac LN, liver,MLN S, C 3, 3, 5, 5, 9, 9 NR diarrhea, hypophysitis 24 40 M adrenal, ALNS, C, I 5 NR 25 54 M bladder, kidney, liver, R, S, C, I 5, 5, 9 NR MLN,pancreas, RPLN, SQ 26 44 F ALN, SQ S, C, I 5, 5 NR diarrhea 27 46 Fliver, lung, caval LN R, S, C, I 5, 5, 9, 9, 9 NR 28 57 F liver, lung,MLN S, C, I 5, 5, 9, 9 NR 29 52 M lung, RPLN, SQ S, C, I 5, 5, 9, 9 NR30 62 F iliac LN, lung S, I 5, 5, 9, 9, 9, 9, 9 PR (6+) diarrhea 31 59 Mliver, lung MLN S 5, 5, 9 NR diarrhea 32 49 M lung, MLN R, S, C, I 5, 5,9, 9 NR hypophysisis 33 55 F bone, muscle, SQ R, S, C 5, 5, 9, 9 NR 3427 M internal mammary LN R, S, C 5, 5, 9, 9 NR 35 55 M lung, SQ S, C 5.5NR hypophysisis 36 57 M lung S, C 5, 5, 9, 9 NR 37 59 M lung, MLN S, C5, 5, 9, 9, 9, 9 NR hypophysisis 38 35 M kidney, MLN R, S, C, I 5, 5, 9,9 NR 39 50 M liver, lung, pleura S, I 5, 5, 9, 9, 9 NR colitis 40 24 Flung R, S, C, I 5, 9, 9 NR colitis, transaminitis 41 67 M bone, breast,liver, lung, S, I 5, 5, 9, 9, 9 NR spleen, SQ 42 49 M adrenal,clavicular LN, S, I 5, 5 NR dermatitis, diarrhea lung, pleura 43 5 MALN, MLN S, I 5, 5, 9, 9 NR 44 41 M lung, RPLN, SQ S, C, I 5, 5, 9, 9 NR45 29 F ILN, lung, MLN R, S, C, H, I 5, 9, 9 NR 46 46 F adrenal, MLN, SQR, S, C, I 5, 5, 9 NR ALN, axillary lymph node; C, chemotherapy; CR,complete response; F, femal; H, hormonal therapy; I, immunotherapy; LN,lymph node; M, male; MLN, mediastinal lymph node; NR, no response, PR,partial response; R, radiation therapy; RP, retroperitoneal; S, surgery;SQ, subcutaneous “+” indicates ongoing response *Responses as of May 18,2005 **including severe ocular toxicity

2.10.1. Clinical Responses

Five of 46 patients (11%) (Table 1) satisfied criteria for objectiveclinical responses after treatment at 9 mg/kg (Table 2). To date, fourof the five patients have ongoing responses, which have lasted over sixmonths.

TABLE 2 Incidence of anti-tumor responses and autoimmunity in patientsby dose level Dose 3 mg/kg 5 mg/kg 9 mg/kg all doses Responders 0 0 5 5/46 (11%) Grade III/IV or severe 1 5 12 18/46 (39%) ocularautoimmunity Responders with auto 0 0 3 3* immunity *p = 0.37, Fisher'sExact Test comparing responders with autoimmunity to nonresponders withautoimmunity

Patient 1 achieved an objective partial response in lymph nodes of theretroperitoneum, pre-aortic, and peri-pancreatic areas after receivingMDX-010 at four doses of 3 mg/kg, two doses of 5 mg/kg, and two doses of9 mg/kg. Patient 1 received a final course of 9 mg/kg beforeexperiencing hypophysitis and, to date, remains a responder at over 12months. Patient 4 experienced regression of multiple lung metastasesafter two doses of MDX-010 each at 3 mg/kg, 5 mg/kg, and 9 mg/kg withoutgrade III/IV autoimmune toxicity. Patient 4 received two additionalcourses at 9 mg/kg and, to date, remains a partial responder for over 12months. Patient 7 achieved complete regression of peri-portal andperi-pancreatic lymph nodes, and partial regression of a peri-aorticlymph node after two doses of MDX-010 each at 3 mg/kg, 5 mg/kg, and 9mg/kg without grade III/IV autoimmune toxicity. Patient 7 received twoadditional courses at 9 mg/kg and, to date, remains a responder at over11 months. Patient 10 experienced complete regression of anintramuscular lesion and partial responses in multiple lung lesionsafter receiving two doses of MDX-010 each at 3 mg/kg, 5 mg/kg, and 9mg/kg. Patient 10 remained a partial responder for nine months beforegrowth of new lung lesions. Patient 30 achieved a partial response in aniliac lymph node and a lung lesion after receiving two doses of MDX-010at 5 mg/kg, and 4 doses at 9 mg/kg. Patient 30 received an additionaldose at 9 mg/kg before experiencing grade III autoimmune diarrhea and,to date, remains a partial responder at over six months.

2.10.2. Autoimmune Effects

Eighteen patients (39%) experienced 21 grade III/IV autoimmune events orsevere ocular toxicity requiring steroid treatment (Tables 1 and 2).These events consisted of: anterior uveitis (1), arthritis (1),colitis/diarrhea (7), dermatitis (2), hypophysitis (8), transaminitis(1), and tubulointerstitial nephritis (1) (Tables 1 and 3). Of these 18patients who experienced severe autoimmune toxicity, 3 (17%) wereobjective clinical responders, whereas of the 28 patients who did notexperience severe autoimmunity, 2 (17%) were responders (p=0.37,Fisher's Exact Test). In addition, 10 patients experienced 11 grade I/IIautoimmune events including alopecia areata (1), anterioruveitis/episcleritis (1), arthritis (1), diarrhea (3), dermatitis (4),and hypopigmentation (I) (Table 3). Five of these patients hadconcurrent grade III/IV autoimmune toxicity. Thus, 23 patientsexperienced autoimmunity at any grade. Analysis of these patientsresulted in 4/23 (17%) of patients with autoimmunity that experiencedtumor regression, and 1/23 (4%) of patients without autoimmunity thatexperienced tumor regression (p=0.35, Fisher's Exact Test).

TABLE 3 Number of autoimmune toxicities by severity Grade Grade ToxicityI/II III/IV alopecia areata 1 0 anterior uveitis 1 1 arthritis 1 1colitis/diarrhea 3 7 dermatitis 4 2 hypophysitis 0 8 hypopigmentation 10 transaminitis 0 1 tubulointerstitial nephritis 0 1 11 21

2.10.3. Pharmacokinetics

Peripheral blood samples were obtained immediately prior to antibodyadministration and one hour post-infusion from patients who begantreatment at 3 mg/kg of CTLA-4 antibody in order to analyze the effectof increasing antibody doses on both peak and trough plasma levels ofthe antibody. Trough levels increased proportionally from belowdetection levels to 68.9 ug/mL with increasing doses and concentrationsof CTLA-4 antibody. Similarly, peak levels increased proportionally from55.8 ug/mL to 356.3 ug/mL with increasing doses and concentrations ofantibody, though levels appeared to stabilize with repeated dosing at 9mg/kg (Table 4). Plasma concentrations of CTLA-4 antibody measuredbefore and after doses of 3 mg/kg were comparable to peak and troughplasma concentrations from patients treated on previous protocols wherepatients received antibody doses of 3 mg/kg.

TABLE 4 Pharmacokinetics of CTLA-4 antibody administration SampleTimepoint N PK concentration (ug/mL) pre-treatment 13 BD post 3 mg/kg ×1 5 55.8 ± 6.1 pre 3 mg/kg × 2 3 17.4 ± 2.9 post 3 mg/kg × 2 2 116.2 ±15.4 pre 5 mg/kg 4 25.5 ± 1.3 post 5 mg/kg × 1 3 131.5 ± 66.8 pre 5mg/kg × 2 4 29.6 ± 9.3 post 5 mg/kg × 2 3 193.1 ± 30.7 pre 9 mg/kg 1048.0 ± 4.9 post 9 mg/kg × 1 3  287.0 ± 109.8 pre 9 mg/kg × 2 5  60.0 ±12.4 post 9 mg/kg × 2 3 366.4 ± 28.6 pre 9 mg/kg × 3 5 63.7 ± 8.6 post 9mg/kg × 3 4 342.8 ± 68.2 pre 9 mg/kg × 4 2 68.9 ± 7.3 post 9 mg/kg × 4 3356.3 ± 74.2 reported as the mean concentration ± the standard error ofthe mean BD = below detection

2.10.4. Phenotypic Changes

Using flow cytometry, pre- and post-treatment peripheral blood sampleswere analyzed for changes in surface expression of T-cell activationmarkers (Table 5). Samples were obtained immediately prior to eachcourse (three weeks after the prior course of treatment) in order toanalyze the effect of increasing antibody doses on the activation ofT-cells. Peripheral blood was stained for both CD3 and CD4 surfaceexpression. Patients for whom a pre-treatment sample and at least onepost-treatment course sample was available were used for analysis,including three of the five responders. CD25+ surface expressiondecreased significantly on CD4+ cells after 5 mg/kg and 9 mg/kg. HLA-DRexpression increased significantly both on CD4+ and CD8+cells. CD69expression trended towards a decrease on both CD4+ and CD8+ cells, whileCD45RO+ expression increased on both CD4+ and CD8+ cells.

TABLE 5 Flow cytometric analysis of selected T-cell surface markers inperipheral blood of patients receiving escalating doses of anti-CTLA-4antibody Mean % Δ 0 to 3 mg/kg 0 to 5 mg/kg 0 to 9 mg/kg N 18 24 12CD25+ (% CD3+ CD4+) −0.5 −4.7 −6.8 p-value 0.8 0.006 0.03 HLA-DR+ (%CD3+ CD4+) +10.1 +10.7 +13.2 p-value 0.0002 <0.0001 0.0001 HLA-DR+ (%CD3+ CD4−) +11.0 +8.5 +11.5 p-value 0.01 0.002 0.003 CD69+ (% CD3+ CD4+)−11.2 −5.6 −10.5 p-value 0.04 0.1 0.1 CD69+ (% CD3+ CD4−) −12.8 −11.4−18.6 p-value 0.01 0.004 0.007 CD45RO+ (% CD3+ CD4+) +3.9 +5.7 +9.8p-value 0.02 0.0005 0.007 CD4SRO+ (% CD3+ CD4−) +6.0 +4.2 +7.0 p-value0.03 0.06 0.04 two-tailed p-value using paired T-test

Five of the 46 patient treated with MDX-010 administered in anescalating dosage regimen exhibited a response to the regimen. Of these5 patients, 2 patients exhibited a response without grade III/IVautoimmune toxicity, and 1 of these 2 patients had tumor regressionwithout autoimmune toxicity. These results show the therapeuticeffectiveness and tolerability of an escalating dosage regimen of aCTLA-4 antibody.

The present invention is not to be limited in scope by the specificembodiments described herein. Indeed, various modifications of theinvention in addition to those described herein will become apparent tothose skilled in the art from the foregoing description. Suchmodifications are intended to fall within the scope of the appendedclaims.

All references cited herein, including all patents, published patentapplications, published scientific articles, protocols, and GenBankAccession Numbers are incorporated by reference in their entireties forall purposes.

What is claimed is:
 1. A method for treating a solid tumor in a patientcomprising administering a CTLA-4 antibody to the patent according to adosage escalation regimen, which comprises: (a) administering a firstCTLA-4 antibody dosage and then administering one or more increaseddosages of the CTLA-4 antibody to the patient until the dosage resultsin a complete response in the patient; and (h) when the patentexperiences a complete response, administering two additional cycles ofthe CTLA-4 antibody at the dosage level that resulted in the completeresponse.
 2. The method of claim 1, wherein the first CTLA-4 dosage isfrom about 3 mg/kg to about 10 mg/kg.
 3. The method of claim 2, whereinthe first CTLA-4 dosage is 3 mg/kg or 5 mg/kg.
 4. The method of claim 1,wherein the solid tumor is selected from the group consisting ofmelanoma, prostate cancer, lung carcinoma, pancreatic cancer, and renalcell carcinoma.
 5. The method of claim 1, wherein the CTLA-4 antibody isa human sequence antibody.
 6. The method of claim 1, wherein the CTLA-4antibody is MDX-010.
 7. The method of claim 1, wherein the completeresponse is disappearance of the measurable tumor for greater than orequal to one month.
 8. The method of claim 1, wherein each one of thetwo additional cycles comprises one administration of a CTLA-4 antibodydosage.
 9. The method of claim 1, further comprising administering achemotherapeutic agent to the patient.
 10. The method of claim 9,wherein the chemotherapeutic agent is selected from the group consistingof paclitaxel, carboplatin, cisplatin, etoposide, and combinationsthereof.
 11. The method of claim 1, wherein the dosage escalationregimen comprises a linear increase in CTLA-4 antibody dosage.
 12. Themethod of claim 1, wherein the dosage escalation regimen comprises astepwise increase in CTLA-4 antibody dosage.
 13. The method of claim 1,comprising administering a CTLA-4 antibody dosage every one to eightweeks.
 14. The method of claim 13, comprising administering a CTLA-4antibody dosage every three weeks.
 15. The method of claim 1, furthercomprising administering a vaccine to the patient.
 16. The method ofclaim 15, wherein the vaccine comprises gp100, tyrosinase, MART-1 or acombination thereof.
 17. The method of claim 1, further comprisingadministering a cytokine to the patient.
 18. The method of claim 17,wherein the cytokine is 1L-2.